Managed Care: Techniques and Legal Implications

* Describe the common techniques of managed care, including limitations on patients and providers, anti-trust concerns, and proposed legislation to protect both patients and providers.

* Discuss important legal, ethical, and policy implications of managed care for Tri-state Health Care, Inc., as well as politically-competent guidelines to consider when proposing new policy changes for Tri-state in the area of managed care.

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Hi,

Let's take a closer look at these interesting questions through discussion, research and examples.

1. Describe the common techniques of managed care, including limitations on patients and providers, anti-trust concerns, and proposed legislation to protect both patients and providers.

Managed care refers to a variety of techniques for influencing the clinical behavior of health care providers and/or patients, often by integrating the payment and delivery of health care. The overall aim of managed care is to place administrative control over cost of, quality of, or access to health care services in a specific population of covered enrollees. http://depts.washington.edu/bioethx/topics/manag.html

Please refer to the attached article: Managed Care and Techniques.doc for specific techniques used in managed care.

a. Limitations on patients and providers

Cost containment often compromises quality care (e.g., work longer hours, see more patients, overworked, make more mistakes, and so on) and the doctor-patient relationship (e.g., les time spent per patient)

See attached article for a full discussion of the limitations of managed care techniques.

For example, according to one source:

"Managed care is structured around a variety of incentives to encourage the practice of cost-effective medicine, and to minimize variation in clinical practice patterns. "Efficiency" here means providing a product, in this case health care, while minimizing resources used, most often dollars. Most often, increasing productivity while fixing cost maximizes efficiency. Hence, managed care may create pressure to do more with less: less time per patient, less costly medicines, and fewer costly diagnostic tests and treatments." http://depts.washington.edu/bioethx/topics/manag.html

According to another source:

Unfortunately, there are at least two inherent limitations to the use of industrial management principles (managed care ideology) in medicine. The first is that not all medical processes are suitable for standardization. The second is that the Axiom of Industry simply does not hold true when you are treating patients.

First, the methodologies of managed care work best - indeed, they only work at all - when you're dealing with a process that can be broken down into a predictable series of reproducible tasks that will generate reproducible results. In other words, industrial management tools work best when the process of care is similar to the process of making widgets. And to the extent that the health care "task" being managed is widget-like, managed care tools such as critical pathways can be highly effective; but not always. Some tasks do not follow this type of strict pathway (see examples at http://www.yourdoctorinthefamily.com/grandtheory/section4_3.htm).

The second inherent limitation in applying the principles of managed care, and of covert rationing (e.g., cost containment), is that the Axiom of Industry simply does not hold true in medicine. In health care, standardization does not always both improve outcomes and reduce cost. It is inarguable that in health care, better is not always cheaper. Sometimes, highly effective treatments are extraordinarily expensive, and applying such treatments to every patient who needs them can be extraordinarily costly. Other times, the cheaper of two acceptable medical therapies will be measurably less effective than the other. Therefore, standardizing medical processes in order to optimize outcomes will sometimes increase overall costs; and standardizing medical processes in order to optimize cost will sometimes lead to diminished outcomes. Like it or not, at least occasionally you will have to choose one goal over the other (see examples at http://www.yourdoctorinthefamily.com/grandtheory/section4_3.htm).

Click on the following links for more information about Managed Care: PLEASE SEE ATTACHED RESPONSE FOR LINKS

Solution Summary

This solution describes the techniques of managed care, including limitations on patients and providers, anti-trust concerns and proposed legislation to protect both patients and providers. It also discusses important legal, ethical, and policy implications of managed care, as well as politically-competent guidelines to consider when proposing new policy changes in the area of managed care. Supplemented with two highly informative articles on managed care techniques and the anti-trust challenges linked to managed care.